Critical Appraisal of the Article How long should outpatient pulmonary rehabilitation be - Essay Example

? Critical Appraisal of the Article How long should outpatient pulmonary rehabilitation be? A randomized controlled trial of 4 weeks versus 7 weeks Name: Institution: Introduction In the contemporary field of medical research, practitioners are required to adopt evidence-based medicine (EBM) strategies. This implies integrating clinical expertise, with patients’ needs, preferences and values, in addition to the most appropriate research evidence, into the course of decision-making. EBM practices largely focus on patients or research subjects, and involve posing well-focused queries, extensive researching for suitable evidence, evaluating acquired evidence for credibility, and finally implementing the outcome to patients’ care. This involves utilization of a specialized model, known as PICO, to create questions and assist in literature review. PICO is an acronym representing population, intervention, comparison, and outcome. This instrument is used herein to critically review the article titled “How long should outpatient pulmonary rehabilitation be? A randomized controlled trial of 4 weeks versus 7 weeks.” In this article the four PICO elements are included in the discussion, as is evident from patient selection; there is also a study protocol, which represents intervention measures. Additionally, comparison between and within groups is clearly outlined, and so is the outcome. Discussion As the title of the journal article suggests, the study was a randomized and controlled trial. The subject population, which comprised of one hundred COPD patients, was randomly assigned to the usual pulmonary rehabilitation (PR) program that lasts for seven weeks, as well as, a four week PR program. Measurement bases or intervention measures used included the Endurance Shuttle Walk Test (ESWT), and Incremental Shuttle Walk Test (ISWT). During this research, the scholars drew statistical comparisons within and between the respective groups. Did the trial address a clearly focused issue? Evident from the PICO model above, the article seeks to provide evidence based information to medical practitioners. It is also discernible from its title, that the trial article is clearly focused on determining the suitable duration for a pulmonary rehabilitation program. Specificity is further emphasized by the scholars focus on four and seven-week PR programs, as well as, selection of COPD patients. Rather than just studying subjects of random demographics, the scholars settled for males and females falling within the 70 to 78 age bracket, and whose COPD is stable. This is important as it avoids ambiguity that would arise if COPD patients from a widely varying age bracket are examined. Additionally, stability of COPD patients provides assurance that, reactions to PR would not vary too radically thus providing inconclusive results. Was the assignment of patients to treatments randomized? As suggested by the article’s title, the trial of COPD subjects is randomized. This is done by dividing the group of one hundred patients into two, one subject to the four-week PR program, and the other to the seven-week therapy plan. This randomization plan, however, does not show the basis for assignment of subjects to either group. It would have been better for the researchers to show the mode of randomization, in order to provide sufficient proof that, indeed either group gave a fair representation of the entire population. Were all of the patients who entered the trial properly accounted for at its conclusion? The scholars account for every subject, showing those that completed the programs and those that did not. For instance, in both groups, 41 patients completed, while nine failed due to reasons such as COPD exacerbation and other ailments, as well as, personal reasons. Accounting for patients is important, as it shows that the greater percentage of the subject population successfully engaged in the trial and it is also an indicator that results are indicative of the entire study. Were patients, health workers and study personnel ‘blind’ to treatment? In research work involving active participants, it is necessary for both subjects and health workers to be blinded, in order to prevent them from directly or indirectly influencing the outcome. In this case, patients’ contact with researchers only took place when advising them to contact the PR section in case of symptom exacerbation. Further evaluations were conducted by a non-partisan in the PR program, thus safeguarding results. However, participants in the trial were not blinded in regard to the duration of the pulmonary rehabilitation program. This is a factor that could have influenced their willingness to engage in home training, hence increasing their activity and possibly altering the results, albeit at a minimal level. Were the groups similar at the start of the trial? The groups are fairly the same, especially in consideration of male to female ratios, age and COPD influencing factors like FEV and tobacco smoking. However, this is information only provided in the comparison section of the paper, after the groups had already started the rehabilitation program. It is, therefore, difficult to tell from the initial assessment whether the groups were similar. The researchers only indicate that all participants had COPD and that they were randomly assigned into the two groups. However, they do not provide information to confirm whether after randomization the groups had equal representation of participants in regard to age, gender, extent of COPD symptoms or even social class. Aside from the experimental intervention, were the groups treated equally? Patients in both the four-week and seven-week rehabilitation programs got equal treatment. For instance, they all attended PR education discussions and seminars covering dietary and disease concerns, medication and breathing control advice. The patients also underwent equal durations of aerobic such as walking and training, under supervision. All participants were also required to walk at a regulated speed of 85% based on ISWT calculations. The only difference between the two groups was that the four-week group missed a small fraction of the PR seminars and got comprehensive manuals covering the relevant topics. How large was the treatment effect? The results of the study were provided by patients, through filling the breathing problems and chronic respiratory questionnaires. The overall research showed that there were no standard disparities in pulmonary function, sex distribution, or age between the studied groups. Additionally, neither group depicted significant change when researchers compared study dropouts with subjects that successfully completed the respective programs (Sewell et al., 2006). How precise was the estimate of the treatment effect? When comparing the two groups at the end of the seven-week program, researchers used 95% confidence intervals (17.0 to 232.2), to establish outcome measure. This implies that a resultant p value of 0.05 or more was perceived to be statistically significant. Based on these statistical measures, the only significant outcome measure was the ESWT, with the average difference between the two groups being 124.6 seconds and a p value of 0.024. These values show that the treatment effect estimate was precise. Were all important outcomes considered? The trial utilized four principal outcome measures including the Endurance Shuttle Walk Test (ESWT), Incremental Shuttle Walk Test (ISWT), Breathing Problems Questionnaire (BPQ) and the Chronic Respiratory Questionnaire-Self Reported (CRQ-SR). These measures were all intended to examine the reaction of patients in the two groups to PR over the respective tie periods. These outcomes were considered for each group singly, as well as, in comparison to each other. For instance, when the supervised rehabilitation program came to an end, the 4-week ESWT performance was better than the other group, by 116.9 seconds. CRQ-SR, BPQ and ISWT differences were not statistically significant. Conclusion Can the results be applied to the local population? The study showed that a reduced 4 week PR program, with adequate supervision has the capacity of attaining similar outcome to a 7 week PR program. The trial’s results can, therefore be applied to the local populace. Are the benefits worth the harms and costs? This was a highly crucial research whose benefits outweighed costs and harms, since it showed that medical practitioners can adopt the shorter program. This will ultimately make it possible for more COPD patients to gain access to PR, unlike currently when many cannot afford the seven-week program. Reference Sewell, L. Singh, S. & Williams, J. et al. (2006). How long should outpatient pulmonary rehabilitation be? A randomized controlled trial of 4 weeks versus 7 weeks. Thorax, 61: 767-771. Read More